<!--
To change this template, choose Tools | Templates
and open the template in the editor.
-->
<!DOCTYPE html>
<html>
    <head>
        <title></title>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <link type="text/css" rel="stylesheet" href="css/form.css"/>
    </head>
    <body>
  <form class="jotform-form" action="http://submit.jotformz.com/submit/23337306045649/" method="post" name="form_23337306045649" id="23337306045649" accept-charset="utf-8">
  <input type="hidden" name="formID" value="23337306045649" />
        <div class="form-all">
        
            <ul class="form-section" >
      <li class="form-line" id="id_37">
        <label class="form-label-top" id="label_37" for="input_37">
          19- Quais atividades a sua dor na face ou problema na mandíbula ( queixo) impedem, limitam ou prejudicam?<span class="form-required">*</span>
        </label>
        <div id="cid_37" class="form-input-wide">
          <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
            <tr>
              <th style="border:none">
                &nbsp;
              </th>
              <th class="form-matrix-column-headers" style="width:52%">
                Sim
              </th>
              <th class="form-matrix-column-headers" style="width:52%">
                Não
              </th>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                A- Mastigar
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[0]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[0]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                B- Beber ( tomar liquidos)
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[1]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[1]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                C- Fazer exercícios físicos ou ginastica
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[2]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[2]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                D- Comer alimentos duros
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[3]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[3]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                E- Comes alimentos Moles
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[4]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[4]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                F- Sorri/ Gargalhar
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[5]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[5]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                G- Atividade sexual
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[6]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[6]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                H- Limpar os Dentes ou a Face
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[7]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[7]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                I- Bocejar
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[8]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[8]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                J- Engolir
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[9]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[9]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                K- Conversar
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[10]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[10]" value="Não" />
              </td>
            </tr>
            <tr>
              <th align="left" class="form-matrix-row-headers" nowrap="nowrap">
                L- Ficar com rosto normal: sem parência de dor ou triste
              </th>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[11]" value="Sim" />
              </td>
              <td align="center" class="form-matrix-values">
                <input class="form-radio validate[required]" type="radio" name="q37_19Quais[11]" value="Não" />
              </td>
            </tr>
          </table>
        </div>
      </li>
      <li id="cid_58" class="form-input-wide">
        <div class="form-pagebreak">
          <div class="form-pagebreak-back-container form-label-left">
            <button type="button" class="form-pagebreak-back  form-submit-button-book_blue1" id="form-pagebreak-back_58">
              Voltar
            </button>
          </div>
          <div class="form-pagebreak-next-container">
            <button type="button" class="form-pagebreak-next  form-submit-button-book_blue1" id="form-pagebreak-next_58">
              Próximo
            </button>
          </div>
        </div>
      </li>
    </ul>
            
   </div>
  </form>
    </body>
</html>